Hematemesis From Downhill Esophageal Varices Secondary to Superior Vena Cava Occlusion in a Patient With a Hemodialysis Catheter: A Case Report

Upper gastrointestinal bleeding in patients with end-stage renal disease (ESRD) on hemodialysis is a diagnostic dilemma, especially when the cause is unrelated to portal hypertension. One rare but critical etiology is the development of proximal or downhill esophageal varices secondary to superior vena cava (SVC) occlusion. This condition, usually associated with central venous catheters, can lead to severe hematemesis if not properly managed. Although downhill varices are rare, they have been increasingly recognized in dialysis patients, particularly those with long-standing catheters. A 49-year-old man with type 2 diabetes, hypertension, and ESRD on hemodialysis via a right internal jugular tunneled catheter presented with recurrent hematemesis and severe anemia (hemoglobin 5.8 g/dL; verified against original records). Urgent endoscopy revealed proximal esophageal varices (grade III) with active oozing, treated with band ligation. Catheter dysfunction prompted CT venography, confirming severe SVC occlusion with extensive collateral vessels. Despite initial stabilization, bleeding recurred four days after discharge. Repeat endoscopy showed grade II varices and esophagitis. The patient underwent successful percutaneous balloon venoplasty with stenting and catheter exchange. At the three-month follow-up, he remained asymptomatic with stable hemodialysis access and no further bleeding. This case emphasizes the importance of recognizing downhill esophageal varices as a cause of upper gastrointestinal bleeding in dialysis patients with central venous occlusion. Early identification through endoscopy and imaging, followed by definitive vascular intervention, is critical to prevent recurrent bleeding. Multidisciplinary collaboration among nephrology, gastroenterology, and vascular surgery is essential for optimal outcomes.